Provider Demographics
NPI:1225215361
Name:ILLA, MAIA ALEXIS (LCSW)
Entity Type:Individual
Prefix:
First Name:MAIA
Middle Name:ALEXIS
Last Name:ILLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 WALL ST.
Mailing Address - Street 2:STE. 5
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-7800
Mailing Address - Country:US
Mailing Address - Phone:530-332-8021
Mailing Address - Fax:
Practice Address - Street 1:315 WALL ST.
Practice Address - Street 2:STE. 5
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928
Practice Address - Country:US
Practice Address - Phone:530-332-8021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1800795471041S0200X
CA670111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool